Integrating COM-B and the person-based approach to develop an ACT based therapy programme to raise self-determination in adolescents with obesity

Background This paper details the development of the Adolescent Intrinsic Motivation ‘AIM2Change’ intervention to support weight-management in young people previously unable to make changes whilst attending a tier 3 weight management service for children and young people. AIM2Change is an acceptance and commitment therapy based intervention that will be delivered one-to-one online over a seven-week period. Methods To develop this intervention, we have triangulated results from a qualitative research study, patient and public involvement groups (PPI) and a COM-B (capability, opportunity, motivation, behaviour) analysis, in a method informed by the person-based approach. Results The integrated development approach yielded a broad range of perspectives and facilitated the creation of a tailored intervention to meet the needs of the patient group whist remaining pragmatic and deliverable. Conclusions The next steps for this intervention will be in-depth co-development of the therapy sessions with service users, before implementing a proof of concept trial. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-023-09930-6.

for many families, where parents usually have the greater control over their child's eating.
Engaging peer support.
Parental modelling of intrinsic motivation and behaviour change driven from intrinsic means.
Challenging stigma and external drivers for change.

Yes
Reflective Motivation: reflective processes, such as making plans and evaluating things that have already happened Patients will need to be prepared to evaluate their values and goals for this approach to work.They will need to develop skills in reflecting on their behaviour (both past and current) as the course goes on and making plans to take forward ideas from the clinic into their everyday behaviour.

Improved self-knowledge of what motivates oneself.
Reflection on past experiences and what helps/hinders in own life.

Yes
Automatic Motivation: automatic processes, such as our desires, impulses and inhibitions Learning skills to inhibit automatic behaviours that allow short-term rewards and to favour a longer-term view, for example targeting the automatic processes that result in emotional/comfort eating.
Developing new behaviours as habits.This will support selfregulation as actions are less focused around conscious decisions.Healthy behaviours become embedded.

Behavioural diagnosis of the relevant COM-B components
Psychological capability; Social Opportunity; Reflective Motivation; Automatic Motivation Stage 2: Identifying intervention content and implementation options.
Step 5. Identify intervention functions.This stage involves using the results of the behavioural diagnosis carried out in Stage 1 to guide decisions regarding the content and delivery of the intervention.This involves first selecting suitable intervention functions (e.g.education, incentivisation) and policy categories (e.g.guidelines, legislation).(Fig. 1) Based upon these decisions, suitable BCTs are identified for inclusion in the intervention before finally deciding upon a suitable mode of delivery.
First, the intervention functions most suited to target the domains identified in the COM-B behavioural analysis carried out in stage 1 were selected using established links between COM-B and intervention functions (Table 1).The identified intervention functions suitable in the context of the target behaviours are then considered using APEASE criteria (affordability, practicability, effectiveness/cost-effectiveness, acceptability, side-effects/safety, equity) which allowed for evaluation of the appropriateness of the identified functions for incorporation into the intervention.

Yes Enablement
Using ACT to increase selfdetermination will hopefully help reduce barriers patients have so far found in their weight management.

Yes
Selected intervention functions:

Modelling, enablement, training & education
Step 6: Identify policy categories Of the seven policy categories, as listed below in Table 2, use APEASE criteria to identify the categories best suited to deliver the identified intervention functions within the resource constraints of the work.Stage 3: Identify content and implementation options.
Step 7: Identify behaviour change techniques.
Whilst the COM-B model traditionally leads us to utilise the behaviour change taxonomy of 93 individual behaviour change techniques (BCTs) covering all areas of COM-B (capability, opportunity and motivation), in this case the behaviour we are seeking to change is that of intrinsic motivation.For this, a specific set of 21 behaviour change techniques has been devised based on expert consensus (Teixera et al., 2020).As this tailored resource exists, we will continue the COM-B process but with reference to these behaviour change techniques instead, referred to as MBCTsBCTs (Motivational behaviour change techniques).
The suitability and potential efficacy of each identified BCT will be considered, guided by APEASE, to produce a final set of BCTsBCTs for inclusion in the intervention.
We have also considered the BCTs needed to run the wider intervention, based on the area raised in the earlier stages of this behavioural analysis.

Demonstration of the behaviour Yes
Instruction on how to perform a behaviour

Feedback on the behaviour Yes
Feedback on outcomes of behaviour Yes

Self-monitoring of behaviour Yes
Behavioural practice/rehearsal Yes Biofeedback Not practical to deliver.

Graded tasks
Yes if set collaboratively.Explores locus of causality and potential sources of external/introjected regulation and its consequences Yes MBCT 3.

Use noncontrolling, informational language
Use informational, non-judgmental language that conveys freedom of choice, collaboration, and possibility when communicating (avoiding constraining, pressuring, or guiltinducing language).For example, use "might" or "could" instead of "should" and "must".
Avoids being a source of pressure or creating internal pressure, countering external locus of causality for actions.

Explore life aspirations and values
Prompt identification and listing of important life aspirations, values, and/or long-term interests and explore how changes in behaviour (or maintaining the status quo) could be linked to them.
Explores integrity and internal coherence between aspirations, values, and goals/behaviours, which can sustain autonomous regulation.

Provide a meaningful rationale
Prompt client to identify rationale for behaviour change and its maintenance that is tailored, explanatory, and personally meaningful or valuable.
Highlights and reinforces motives/reasons that could form the basis of autonomous motivation.Indicates attention and respect for the person's attitudes, thoughts, perceptions, and feelings, which creates an accepting and warm social environment.

Encourage asking of questions
Prompt the client to pose questions regarding their goals/behavioural progress.
Creates an open and collaborative relationship that promotes trust.

Show unconditional regard
Express positive support regardless of success or failure.
Demonstrates unconditional respect, care and support and promotes warm social environment.

Help develop a clear and concrete plan of action
Develop and provide summary of action plan to work toward a behavioural goal.
Provides structure, increases confidence, and minimizes future failure (and perceived incompetence).

Promote selfmonitoring
Prompt monitoring of progress, skill level, or performance such as suggesting options for monitoring tools/means and metrics for success, including steps in the direction of behaviour change.
Provides structuring information that reinforces success and self-awareness.
Explore ways of dealing with pressure Provide information to manage and limit effects of pressuring contingencies that would undermine competence such as extrinsic rewards, criticism, negative feedback.
Increase confidence to deal with sources of controlling pressure from others and themselves.

Yes
Step 7: Identify mode of delivery.
The final step involves considering the following in relation to intervention delivery: content, provider, recipients, intensity, duration and fidelity.The various potential modes of intervention delivery were considered using the APEASE criteria to assess the options that would be suitable within the constraints and resources of the feasibility trial.

Mobile phone text
The intervention is too complex to be delivered over text.

Needs discussion between therapist and patient Individually accessed online programme
Yes -could be delivered as a remote programme, but patients would potentially lose out through not working with a clinician.Costbenefit analysis required.

Table of changes
The table of changes is an iterative document that has been contributed to following PPI meetings and will be updated throughout the iterative development phase of the intervention.The approach was novel and enabled them to think about their feelings in a way they had not before.Internal/selfmotivation PPI members explained repeated failed attempts at weight loss until they themselves felt they were ready.Our challenge is that the YP's have been referred, we need to tap into a way of getting them ready to start, from a place where they may not have chosen to be referred.
Thought to be v important for successful weight change.Not going to continue with an intervention that "makes them feel rubbish".
GB "Got to have that moment where you think I need to do this for me" and GT agreed need to "decide for myself" to Must do make the change and to stop thinking of healthy eating as a negative thing to be doing, instead framing it as a positive change.
space for internal motivations.

Wholistic
This concept came up in both adult PPI sessions -the importance of seeing the whole person rather than purely focussing on what they eat.BC towards end felt the approach was "empowering, hopeful and for the whole person" The lack of focus on specific food, and more about whole person and behaviour as a strong benefit.Flexible approach as opposed to strict rules.
For those with poor nutritional knowledge, more guidance may be required to establish a healthy diet.
PPI members reflected on their experience of wanting something more because it had been restricted-a flexible approach is preferred.

Exp. NCON
As the clinic already offers nutritional education we hope that patients have learnt during their initial 6-months at the COCO clinic.Dietary guidelines and calorie counting is also offered so this intervention seeks to take a different approach to support those for whom that approach has not worked.

Individualised approach
The importance of making the intervention relevant to the individual's interests and motivations (gave example of his therapist using his interest in cars) Develop individual rapport with patients enabling metaphors and examples to be tailored to their needs EXP, Therapists' confidence with the programme material will need to be considered when thinking about their ability to adapt interventions on the spot.If possible, this would be the Would like to do ideal, but feasibility will need to be reviewed.Logistical factors 1-2-1 sessions Felt that YP need to be a certain age before being able to share their feelings within a group Where to hold the sessions As much choice given to the young people as possible.
Parents joining in the sessions.
Young people may struggle to discuss how they feel in front of parents, especially before they have built rapport with the clinical team enough to feel safe to discuss their feelings.
Holding these discussions in front of family may be particularly sensitive if the young person feels their upbringing and/or home food environment has contributed to their weight problem.
Equally parents may have questions and experiences they want to share with the clincians but not in front of the young person.
Splitting sessions so part is done with the YP alone to develop trust and confidence to share with their PG Or Offering the young person the chance to invite their parent to join or not

REP, EXP, NCON
The young person will get the chance to invite their parent when they want to -session topics will be give a week ahead so young people can make a session by session choice.Currently, no session time has been allocated for parents-only, however this will be reviewed.

Default of inviting the parent to support
The parent may not be the most appropriate support, in some cases a grandparent, or other figure may be the child's key support.
As much choice given to the young person about the session is a good thing.
Young people being given the option to bring an alternative support person, not defaulting to always being the parents.

EXP, NCON
This option will be offered to patients, and continually reviewed.

Could do
Online video as the platform for therapy But might create problems if nowhere to go at home without parents.Don't know who else is there to 'make sure they are saying the right things'.Some cases zoom better, e.g.video off, may help to be relaxed in a comfortable place, more honest.

Terminology Terminology -unhooking
The wording resonated -in particular 'unhooking' and 'hooked' was described to explain how they feel about being absorbed by darker thoughts, with strategies such as going for a walk being 'unhooking' they reflected.
offer several activities to try for each session as individual differences in how each activity will be viewed and received.

/
The use of the term 'Choice' Does choice have connotations of fault and blame?That 'choice' is a difficult word.As YP often told they have choices but often they are already made (by adults, socioeconomic position, genetics -CG).HH "YP may not yet understand that they are in control of their behaviour."That they might not realise they are making choices.JWremembered feeling that she didn't understand her emotions "never mind that I had a choice".Linked to DF (Thurs11th) who felt when muddled, she didn't feel she had a think about how to use the word choice so it avoids negative feelings surrounding not having made good ones previously.Raising awareness of the choices we make all the time -some YP may not be aware or even able to make 'good' choices when feeling emotional and pressured.
Work to be done on explaining the concepts, before then introducing choice as something we would work on giving the YP.Rather than inferring that they have always had choice and have been taking the wrong choice up until this point.choice in the way she behaved around food.

Using the term 'mindfulness'
The term 'mindfulness' is overused especially during school and when stress is discussed.It makes people stop listening as it feels like more of the same.Some adolescent PPI members had positive experiences and a regular mindfulness practice, therefore connecting that the activities were mindfulness allowed them to build on their skills Important to not underestimate young people's interest and engagement: Using the term 'awareness' i.e. bringing your awareness to certain experiences, rather than mindfulness may help tap into the beneficial effects of mindfulness without the cliché preconceptions.

EAU, REP, EXP NCON
Both terms will be used and the preferred language will be discussed with each young person.This is an area for continued monitoring and can be changed if there is a clear pattern.

Specific activities Three mountain metaphor
The metaphor simplifies the challenges of the journey and the external pressures including peer pressure and technology that impact the journey one person felt it could be viewed competitively, so suggested making sure it wasn't viewed as a race or competition The collaborative aspects of the therapy relationship ae clear, the approach of tackling these problems together, with lots of emphasis on how the young person is involved in shaping this process.
it was felt this approach felt "inviting"."Invitation to come on a joint journey" "makes them know it's what they want rather than being told to do something." Ensure that the diagram of the mountain includes notable up's and down's and discuss them in the explanation of the metaphor EAU, EXP, NCON

Yes
Should do Lottery YP's weren't as keen on the lottery example as made them feel selfish.
Found it hard to decide how to see yourself.

Inflatable ball activity
The activity facilitated conversation; it was easier to discuss having done the activity together.
People then built on the metaphor, continuing to use it in new ways to explain how they felt.
"Feel like you described my teenage years" "a new way to consider this".
Strength in that the conversation evolved, with people still using the metaphor to explain how they felt in other situations The choice point video The video simplifies the decision to make the life-enhancing decision, rather than the habitual nonhealthful behaviour.
Video features a very slim woman with protruding collarbones with PPI members found drew their attention.
Video only features a woman.
The video captured attention and offered a concise snapshot of what was perceived as an interesting and novel approach.Left people wanting to know more about the approach.
The video offered hope that there was a solution not just to their weight but to how they were feeling more broadly.
Gave them a sense that they didn't need to feel stuck and left them feeling more positive.
Caveat the video with the understanding that this is a simplified version of what is actually going on.
There are two versions of the video, so ensuring the version with the slim woman is not used.

Exp. NCON Should do
Some of the language/issues were not necessarily the right focus for YP (e.g.financial worries).
Discussions were held about how the video was targeted at adults, but that this wasn't necessarily a negative thing as for many YP's it would be empowering to know that they were being treated as adults.
"Got the point across without being super cringy".

Visualising your mind as a character
Not all people enjoyed trying to draw and visualise their minds.One person who was less keen on the activity felt their mind often encouraged them to engage in the health beneficial behaviours.
Some people found the idea that our mind tells us the same repeated stories useful and enjoyed reflecting on this.

Members explained battling with the two sides of their mind
Assessing where the YP is at individually may help to understand whether this is a useful activity for them EXP, developing the baseline that these are all things to experiment with/try.Some will feel helpful, others may not, and that is okay -we can just keep working with/building on the things that feel they work for that individual.Not everything will work for everyone.
Could do

Fig 1 .
Fig 1.The behaviour change wheel with sources, intervention functions and policy categories (specify PPI, experts, literature) NCON = Does not contradict experience or the guiding principles NC = not changed (give a reason) MoScoW = Must do, Should do, Could do, Would like to do

Table 1 .
Links between COM-B & intervention functions

Table 3 .
Matrix of links between intervention functions and policy categories